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Deficiency Records for Bethany Woods Nursing and Rehabilitation Center

View the most recent health deficiencies and inspection results for Bethany Woods Nursing and Rehabilitation Center. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Bethany Woods Nursing and Rehabilitation Center. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. Fire Safety 2024-12-19 2025-03-13 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-12-19 2025-03-13 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-12-19 2025-03-13 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-12-19 2025-01-16 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-12-19 2025-01-16 Y
Ensure that residents are free from significant medication errors. Health 2024-12-19 2025-01-16 Y
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-09-01 2023-10-17 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2023-09-01 2023-10-17 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-09-01 2023-09-29 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2023-09-01 2023-09-29 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-09-01 2023-09-29 Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2023-09-01 2023-09-29 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-09-01 2023-09-29 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2023-09-01 2023-09-29 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-09-01 2023-09-29 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2023-09-01 2023-09-29 N
Ensure each resident receives an accurate assessment. Health 2023-09-01 2023-09-29 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2023-09-01 2023-09-29 N
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2022-02-03 2022-03-03 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-02-03 2022-03-03 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2022-02-03 2022-03-03 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2022-02-03 2022-03-03 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2022-02-03 2022-03-03 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2022-02-03 2022-03-03 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-02-03 2022-03-03 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-02-03 2022-03-03 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-02-03 2022-03-03 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-02-03 2022-03-03 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-02-03 2022-03-03 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2022-02-03 2022-03-03 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-02-03 2022-03-03 N
Ensure each resident receives an accurate assessment. Health 2022-02-03 2022-03-03 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-02-03 2022-03-03 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-02-03 2022-03-03 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2022-02-03 2022-03-03 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2022-02-03 2022-03-03 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2022-02-03 2022-03-03 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2022-02-03 2022-03-03 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-02-03 2022-03-03 N
Establish staff and initial training requirements. Fire Safety 2022-02-03 2022-03-03 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-02-03 2022-03-03 N

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